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LA REVUE EN SCIENCES INFIRMIÈRES • THE NURSING JOURNAL
Vol.1, Numéro 1/Vol.1, Issue 1. ISSN: 1918-1345
ARTICLE 1
JD JACOB & E SKINNER
EXPOSING THE EXPERT DISCOURSE IN PSYCHIATRY:
A CRITICAL ANALYSIS OF AN ANTI-STIGMA-MENTAL ILL-
5
NESS AWARENESS CAMPAIGN
ARTICLE 2
H POLIQUIN
ANALYSE CRITIQUE ET DIMENSIONNELLE DU CONCEPT DE
SANTÉISATION
17
Commentary 40
Éditorial/Editorial
2015: Vol.7, Numéro 1/Vol.7, Issue 1
Sommaire/ContentÉditorial/Editorial
While producers of the DSM argue that psychiatric diagnoses are real entities (taxon), they are
vague and abstract constructs that lack conceptual boundaries and remain heavily influenced
by socio-political realities.[1] Consequently, it can be argued that the DSM as a “scientific”
instrument is an oxymoron: “the DSM has little to do with science, its content is determined
primarily by the gatekeeping efforts of the small number of influential psychiatrists who have
the directive to decide which disorders will be allowed to appear and which will not”.[2 p179]
In fact, it is the product of individuals who chair committees and who vote on the inclusion
or exclusion of certain diagnostic groups.[3,4] According to Kirk and Kutchins, “to a great
extent psychiatric nosology has been a product of committee meetings and smiling faces”,[5
p29], where psychiatric nosology is not so much about addressing construct validity as it is
seeking to address face validity: professional consensus. It is also important to highlight that
strong financial ties currently bind the developers of the DSM with pharmaceutical and other
companies who are powerful drivers of the psychiatric system.[6]
The construction of mental illness is now largely based on the assumptions that physiological,
genetic, and/or chemical abnormalities are at the roots of behavioural deviance.[7] The
hypothetical association between mental illness and the lack or excess of neurotransmitters
justifies the need to develop molecules meant to restore balance in individuals’ brains.[3] In other
words, the multiple sites of therapeutic action in the brain are at the heart of modern psychiatry.[8]
However, the biological classification of mental disorders serves purposes other than clinical. A
significant outcome of the DSM-III is the growing association between its classification scheme
of mental disorders, insurance coverage of mental “care”,[9,10] and the rising numbers of
chemical compounds produced by pharmaceutical companies--a phenomenon that remains
controversial in light of the fifth edition of the DSM. These relationships form a dense web, a
medical-industrial complex whose members have much to gain financially from additional
diagnostic categories. The rise of biopsychiatry and the concomitant expansion of classification
schemes are of great interest to pharmaceutical corporations whose business objective lies in
the production of drugs that target neurotransmitters’ functions in the brain. Pharmaceutical
companies are pivotal funding agencies in the promotion, development, and dissemination of
(bio)psychiatric research. They therefore constitute powerful instigators (and beneficiaries) of
the fabrication of new psychiatric labels.[11] Along with Kutchins and Kirk,[9] we therefore
2015: Vol.7, Numéro 1/Vol.7, Issue 1
3contend that the unlabelled masses of individuals in today’s societies represent an untapped
resource for the economic growth of corporations, such as pharmaceutical industries, who are
heavily involved in the “psychiatric business.”
The entire text is a shorten version of Introduction in Holmes, D., Jacob, JD., and Perron, A. (2014).
Power and the Psychiatric Apparatus. Ashgate: Surrey.
Jean Daniel Jacob, Associate Professor
Amélie Perron, Associate Professor
Dave Holmes, Professor
University of Ottawa
Faculty of Health Sciences
School of Nursing
References
1.Federman C, Jacob JD, Holmes D. Deconstructing the psychopath. A critical discursive analysis.
Cultural Critique 2009; 72:36-65.
2.Curra J. The Relativity of Deviance. Thousand Oaks: Sage Publications, 2000.
3.Kaplan HI, Sadock BJ. Comprehensive Textbook of Psychiatry. Baltimore: Williams & Wilkins; 1995.
4.Mendelson G. Homosexuality and psychiatric nosology. Australian and New Zealand Journal of
Psychiatry 2003; 37:678-83.
5.Kirk SA, Kutchins H. The Selling of DSM. The Rhetoric of Science in Psychiatry. Hawthorne: Aldine de
Gruyter, 1992.
6.Cosgrove L, Krimsky S, Vijayaraghavan M, Schneider L. Financial ties between DSM-IV panel members
and the pharmaceutical industry. Psychotherapy and Psychosomatics 2006; 75(3):154-60.
7.Breggin P. Politics, practice and breaking news. Ethical Human Psychology and Psychiatry 2006;
8(1):3-6.
8.Breggin P. Psychopharmacology & human values. Journal of Humanistic Psychology 2003;43:34-49.
9.Kutchins H, Kirk SA. Making Us Crazy. New York: The Free Press, 1997.
10.Mayes R, Horwitz AV. DSM-III and the revolution in the classification of mental-illness. Journal of
History of the Behavioral Sciences 2005;41(3):249-67.
11.Moncrieff J, Hopker S, Thomas P. Psychiatry and the pharmaceutical industry: who pays the piper?
Psychiatric Bulletin 2005; 29:84-5.
2015: Vol.7, Numéro 1/Vol.7, Issue 1
4Abstract
1
Drawing on a situational analysis of a recent anti-stigma campaign in psychiatry (Defeat Denial: Help Defeat
Mental Illness) this paper seeks to engage with the reader on the use of an expert discourse that focuses on
the brain and its disruption as a way to address stigma associated with mental illness. To begin, we briefly
highlight key statistics regarding the impact of mental illness in Canada and introduce the concept of stigma.
We then introduce the Defeat Denial media campaign and describe the analytical process employed for
this paper - Situational Analysis with a specific focus on discourse. We then expand on the use of the expert
discourse in the awareness campaign by making connections with Rose’s concept of biological citizen and,
in the final sections, present recent studies on stigma that highlight the paradox and contested construction
of the (bio)psychiatric self.
Key Words biopsychiatry, mental illness, public health campaigns, stigma
Exposing the Expert Discourse in the form of mass media awareness campaigns and, more
specifically, the ways in which these messages seek to brand
Psychiatry: A Critical Analysis of an
the issue of stigma related to mental illness.
Anti-Stigma/Mental Illness Awareness
We recently engaged in the examination of a public health
Campaign
campaign produced by the Centre for Addiction and Mental
Health (CAMH) in Toronto (Ontario, Canada) aimed at
JEAN DANIEL JACOB & ELISE SKINNER enhancing mental illness awareness and combating stigma
both at the individual and societal levels. In so doing, our
objective was to critically examine the 2012 awareness
Introduction campaign Defeat Denial[3] and make explicit the discourses
embedded in the campaign. Drawing upon this research,
Over the last two decades, public health initiatives to address
this paper seeks to engage with the reader on the use of an
both the burden of mental illness and its associated stigma
expert discourse that focuses on the brain and its disruption
have gained significant momentum.[1] In parallel with the
as a way to address stigma associated with mental illness. To
growing realization that people with mental illnesses suffer
begin, we briefly highlight key statistics regarding the impact
from both their disorders and the stigma that accompanies
of mental illness in Canada and introduce the concept
them,[2] we have witnessed the deployment of initiatives
of stigma. We then introduce the Defeat Denial media
that seek to diminish both their occurrences and impacts.
campaign and describe the analytical process employed
Of particular interest for this paper are the ways in which
for this paper - Situational Analysis with as a specific focus
mental illness information is conveyed to the public in
on discourse.[4] We then expand on the use of the expert
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EXPOSING THE EXPERT DISCOURSE IN PSYCHIATRY
discourse in the awareness campaign by making connections these authors, stigma occurs when the following interrelated
with Rose’s concept of “biological citizen”[5] and in the final components converge: people distinguish and label human
sections, present recent studies on stigma that highlight the differences; dominant cultural beliefs link labeled persons
paradox and contested construction of the (bio)psychiatric to undesirable characteristics (negative stereotypes); labeled
self. persons are placed in distinct categories so as to accomplish
some degree of separation of “us” from “them”; labeled
Mental illness and stigma persons experience status loss and discrimination that lead
With an unprecedented impact on health, mental illness to unequal outcomes. Link and Phelan[13] thus highlight
leaves no segment of Canadian society unaffected. It is that inherent to stigma is the exercise of power, whereby
estimated that 3% of the Canadian population experience “stigmatization is entirely contingent on access to social,
serious mental illness and 17% experience mild to moderate economic, and political power that allows the identification
mental illness.[6] In 2011, 5.6% of Canadians over the of differentness, the construction of stereotypes, the
age of 12 perceived their mental health as fair or poor.[7] separation of labeled persons into distinct categories, and
According to the Mental Health Commission of Canada,[8] the full execution of disapproval, rejection, exclusion, and
seven million Canadians will need help for mental health discrimination”.[13 p367] Adding to this, the World Health
concerns each year, and every day, 500,000 Canadians miss Organization[14] suggests a broader relationship between
work due to psychiatric reasons. Dewa et al.[9] estimate the misinformation and stigma:
economic burden of mental illness and addiction in Canada “Politicians and the general public are only partly
aware of the fact that effective treatment of most
to be $51 billion annually. mental disorders is possible. The image of mental
illness is contaminated with images of violence, sin
Compounding these findings is the impact of stigma attached and laziness. Most health workers are not conversant
to mental illness. It is estimated that 60% of people with a with modern methods of treatment of mental illness
and often do not possess the necessary skills to deal
mental health problem or illness will not seek help for fear of with it. Among them there are many who believe
being labeled.[8] According to the Ontario Ministry of Health that the only way of dealing with mental illness is
long term hospital care. In the majority of countries,
and Long Term Care, the public is more inclined now than including developed ones, there is no parity of care
it was “a few decades ago to perceive people with mental for mental and physical illnesses. Stigma of mental
illness as dangerous”.[10 p41] The stigma associated with illness gains strength from these misconceptions and
reinforces them.”
mental illness and addiction is often based on misconceptions
such as: the association between mental illness and violence; Although it is important to contextualize the situations
mental illness is a single, rare disorder; people with mental in which stigma occurs, it is also important to understand
illness or addiction are poor and less intelligent; and, mental how stereotypical views and categories (often portrayed
illness or addiction is caused by a personal weakness (Mental in the forms of labels), as sources of information, shape
Health Commission of Canada, as cited by Ontario Ministry interactions with oneself and with others. According to
of Health and Long Term Care.[10 p41] It follows that people Link and Phelan,[13 p369] categories and stereotypes are
with a mental illness often describe the associated stigma as often “automatic” and facilitate “cognitive efficiency”.
more life-limiting and disabling than the illness itself.[8] The automatic nature of this thought process is revealed in
research indicating that categories and stereotypes are used
Conceptualizations of stigma often build upon the work
in making rapid judgments and thus appear to be operating
of Goffman[11] that defines “stigma as “an attribute that
preconsciously.[13] What makes these elements dangerous
is significantly discrediting” and that serves, in the eyes of
is the inherent lack of critique that labels imply and the
society, to reduce the person who possesses it”.[12 p14]
automatic images that they can create in a person’s mind.[15]
According to Link and Phelan,[13] what is most important in
For example, labelling mental illness as a disruption in
identifying the meaning of stigma is the culturally mediated
brain circuitry (as explored in this paper) is a label that
and temporally located relation between the attribute and a
refers to a set of preconceived understanding regarding
stereotype. In effect, these authors recognize the centrality
the ontology of behaviours thus indicating how we should
of individual perceptions as well as the consequences that
expect mentally ill people to behave in light of a specific
these perceptions have on social interactions. However,
diagnosis. Concurrently, this label will likely influence how
they reframe the notion of stigma as a social process that
we interact with the labelled individual because of the label’s
can only be understood in relation to broader notions of
implicit assumptions. That is, labels create virtual lines
power imbalances inherent in stigmatization. According to
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EXPOSING THE EXPERT DISCOURSE IN PSYCHIATRY
of differentiation[11] representing a particular process of the feature of the campaign messages were developed by an
classification which will likely shape the social identity of the advisement company and aimed to be both relatable and to
labelled individual and their social interactions with others provoke self-reflection and change.
in a particular context. Indeed, people who are labelled as
The first two stages of the campaign included twenty-six
mentally ill may act less confidently and more defensively,
print ads (as found on the Defeat Denial website) placed in
or they may simply avoid a potentially threatening contact
newspapers, magazines and bus shelters. Of these ads, two
altogether.[13] As further described and researched by Link
were in Spanish and two were in Chinese. The text-based
and Phelan[13 p374] in their literature review, “the result
advertisements have a simple, uncluttered appearance and
may be strained and uncomfortable social interactions with
each is depicted in only white and either soft purple, green,
potential stigmatizers (Farina et al., 1968), more constricted
blue or orange. The upper half to two thirds of each ad features
social networks (Link et al., 1989), a compromised quality of
a phrase representing a cliché or stereotyped/dismissive
life (Rosenfield, 1997), low self-esteem (Wright et al., 2000),
message commonly expressed to people purportedly
depressive symptoms (Link et al., 1997), unemployment and
struggling with mental illness. The clichéd phrases appear in
income loss (Link and Phelan, 1982, 1987)”.
a large font, framed with quotation marks and canvassed on
white. In some of the advertisements, only the cliché phrase
The public awareness campaign: “Defeat Denial”
appears while in others, a response, a question or a short
The Centre for Addiction and Mental Health (CAMH) is counterpoint is offered in smaller font below the prominent
a large Canadian mental health and addiction teaching cliché. In two of the advertisements, several paragraphs
hospital and a research centre in the area of addiction and of text appear and serve to inform a significant part of the
mental health. CAMH launched the first stage of the three- present analysis. The phrases “Defeat Denial. Help Defeat
part Defeat Denial campaign in June 2012.[3] The campaign Mental Illness.” and the CAMH logo appear in the bottom
began with an initial promotion in transit shelters in late right corner while Facebook and Twitter logos appear in the
May 2012. in which CAMH was not named. Centered in the bottom left corner of each ad. The following message is an
Greater Toronto Area, the campaign formally began in early example of the ads presented in the campaign that were used
June 2012 with advertisement spots in theatres, a Toronto for the current analysis. All other posters are available on the
Star Special CAMH section on June 9, as well as billboard, campaign’s website.
subway, radio, newspaper and online advertisements. In the
Dismissive Message: “It’s all in your head.”
aim of encouraging a broader public conversation related to
its objectives, the campaign included an interactive online Additional text: “Or as we’re discovering, your brain.
It’s ironic that one of the phrases people use to dismiss
component, through the social networking sites Facebook and a mental illness actually contains more insight than
Twitter as well as through a website dedicated to the Defeat you might think. Because many mental illnesses are
the result of things that actually happen in your head
Denial campaign. The first stage of the campaign ended in – like disruptions in brain circuitry. By understanding
July 2012. The second stage, described as “informed by the the brain better, we’ll be able to make huge advances
in early detection, diagnosis and treatment. How
conversation generated in the first stage”, was scheduled for important is this? Important enough that $30 million
mid-September to mid-October 2012 and included a video has just been donated to CAMH for next generation
brain science research. Our work will attract the
contest. Although the launch of the third stage was scheduled world’s leading scientists and clinicians and CAMH
for early 2013, it had not yet occurred at the time of drafting will be a beacon to mental health experts around the
this article in May 2014. globe. By deepening people’s understanding of the
brain and the science behind mental illness, we hope
to overcome the stigma and prejudice. Because if we
The Defeat Denial campaign aimed to challenge the stigma truly want to transform lives, we must also transform
associated with mental illness by compelling “people to the way society thinks about mental illness.”
rethink their perceptions of mental illness and addiction,”[3]
The Defeat Denial campaign was part of CAMH’s Strategic
as well as raise awareness about the work of CAMH. It
Plan entitled VISION 2020,[16] which was also launched in
follows that the stated objectives of the campaign were
June 2012. The plan, comprised of six strategic directions,
to, “raise public consciousness about mental illness as an
included “Drive social change,” under which the campaign
issue which needs to be addressed on both a personal and
falls. This direction orients CAMH to “advocate with
societal level,”[3] and “increase public awareness of CAMH
sensitivity and impact,” “respond to mental health priorities
as a leading teaching hospital and research centre, and about
in our environment,” and build “public awareness of mental
our vision for social change”.[3] The familiar clichés used as
illness and addiction.” The direction is one that engages the
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EXPOSING THE EXPERT DISCOURSE IN PSYCHIATRY
organization to transform “society’s understanding of and workplaces, seniors’ service providers, municipal service
attitudes toward mental illness and addiction” and to “fight providers, justice providers and the public;
against prejudice and discrimination.”
• Acknowledge that mental health and addictions services
The campaign is situated in the broader Canadian context, should reflect Ontario’s diversity, and take steps to achieve
in which one can identify a growing movement to transform this.[17]
societal perceptions related to mental health and illness. The
Should the campaign have unfolded as initially scheduled, it
formal inception of this trend can be traced to 2006, when
would have only marginally preceded the publication of the
the Standing Senate Committee on Social Affairs, Science
fifth edition of the Diagnostic and Statistical Manual of Mental
and Technology completed a national review of mental
Disorders (DSM-5) in May 2013. This contextual detail is
health and addiction services in Canada. This marked the
significant to the extent that the DSM does, in some respect,
first and most extensive analysis of the Canadian mental
guide the way mental disorders are conceptualized. In this
health system and a key finding delivered in the Committee’s
case, the expansion of diagnoses proposed for the DSM-5 did
final report, Out of the Shadows at Last: Transforming Mental
not go without opposition from academics, clinicians, etc. as
Health, Mental Illness and Addiction Services in Canada,[6]
the question of its scientific and objective claims were (once
was the lack of national focus for mental health issues in
again) publicly debated.
Canada. The Committee recommended the creation of the
Mental Health Commission of Canada (MHCC), which Situational analysis: Critical mapping as research
would be tasked with, among other things, the delivery of a methodology
ten-year anti-stigma program. This program took the shape of
Opening Minds, established by the MHCC in 2009. Working Situational analysis is a research method that seeks to
with service providers, communities and people with mental expose complexity by way of “elucidating the key elements,
illness and their family supports, the program targets health immaterialities, discourses, structures and conditions that
care professionals, youth, the workforce and the news media characterized the situation of inquiry”.[4 p.xxii] Informed by
as its focus areas for reducing stigma related to mental illness the work of Clarke (2005),[4] this research method lends itself
and for cultivating an environment in which those living with particularly well to critical research projects [4, p.78] and
mental illness feel comfortable seeking help, treatment and has proven to be particularly useful in “exploring the often
support.[8] A central operating tenet of the Opening Minds fleeting/shifting discourses and conditions existing within
initiative has been to “identify, document, and disseminate [specific contexts]”,[18, p.299] “turning up the volume of
best practices in stigma-reduction using networks of existing lesser but still present discourses in a situation”,[19 p130]
programs as community leaders”.[8] This analysis can be and “allowing mute evidences to be heard”.[20 p131] The
situated in the effort to examine the present stigma-reduction strength of this method is based on the construction of various
effort to ultimately contribute to this evolving movement. maps (situational maps, social world/arenas maps, positional
maps) that enable researchers to examine a given situation in
In the same vein, the Defeat Denial campaign can be situated all of its complexity by “generating the kinds of data in which
in the broader provincial political and financial context. The we can find often invisible issues and silences”.[4 p76]
2009 Ontario government discussion paper, Every Door According to Clarke,[4 p.xxii] these cartographic exercises
is the Right Door – Towards a 10-Year Mental Health and or maps, used alone or as part of a larger methodology
Addictions Strategy,[10] identified stopping stigma as a key (i.e. grounded theory), help situate research projects
direction. Followed by the launch of Open Minds, Healthy “individually, collectively, organizationally, institutionally,
Minds – Ontario’s Comprehensive Mental Health and temporally, geographically, materially, discursively, culturally,
Addictions Strategy[17] in June 2011, this strategy, focused symbolically, visually, and historically”. In other words,
on children and youth, paralleled new funding commitments this method enables researchers to draw from various data
taken by the Ontario government in the area of mental to make explicit the complexities at play in a situation and
health. Among the goals of the strategy was to create healthy, help understand its meaning(s), problematize its effect, etc.
resilient and inclusive communities with an expected result For the purpose of this paper, we used Clarke’s cartographic
of less stigma and discrimination in public services and in the exercises as the principal analytic method as it offered a
workplace. Specifically, the Ontario government pledged to: creative and structured analytical process. More precisely,
• Implement more mental health promotion and anti-stigma we focused primarily on the creation of situational maps
practices for children and youth, educators, health providers, (both disorganized and organized) to engage in a relational
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EXPOSING THE EXPERT DISCOURSE IN PSYCHIATRY
analysis and highlight the various discourses at play in the on our analysis, we argue that using a bio-psychiatric
campaign. The method (mapping and relational exercise) framework to challenge individual and societal stigma ought
will be described in the next section of the paper. to be challenged in light of its individual and collective
implications (effects). In the following segment, we will
Despite being a campaign that was highly “visible”, the
expand on the use of the expert discourse in the awareness
main aspects used in the analysis were in the form of text
campaign and its possible stigmatizing effects. As such, we
(as opposed to other mapping exercises that may have
will examine how such a campaign contributes to a broader
included pictures or videos). In this sense, analyzing text
discursive production of otherness using current literature
through situational mapping enabled us to tease out various
on stigma. Although the ensuing analysis is the result of
discourses related to the situation of interest and, in the
a rigorous analytic process, it remains influenced by the
process, draw close attention to power dynamics that are
researchers’ paradigmatic position and theoretical sensitivity
embedded in the campaign messages. For the purpose of
as well as the chosen material of study.
explanation, we must understand this undertaking as a
form of critical discourse analysis; that is, a type of analysis
Research method: Mapping the campaign
that examines written text in search of elements that both
produce and re-produce power relations that may not always Our objective in this paper was to critically examine CAMH’s
be overtly evident.[4] Anchored in Foucauldian thought, awareness campaign along with the discourse materials
critical discourse analysis can, therefore, be understood as a located and collected for the project. In order to explore the
way to unveil the hidden politics embedded in the text which discursive body of the campaign, we turned to important
seek to reinforce the status quo (dominant discourse). In this documents produced by governmental bodies as well as
sense, a given discourse “not only sets limits and restricts leading organizations in mental health at both the provincial
that which can be said about a phenomenon”, but also and national levels. We also reviewed epidemiological data
“empowers certain agents to speak and make representations, on mental illness and scholarly publications in the field of
while also disempowering others from doing so”.[4 p160] mental health and stigma. Finally, we chose the campaign’s
As such, we understand a discourse as a set of statements web based advertisements as the primary discursive terrain
that embody “the historically specific relations between for analysis.
disciplines (defined as bodies of knowledge) and disciplinary Using the cartographic exercises proposed by Clarke,[4
practices (forms of social control and social possibility)”;[21 p187-8] we critically examined the awareness campaign
p26] That is, “in any given historical period we can write, (situation of inquiry) using a cluster of key questions:
speak or think about a given social object or practice
What are the discourses in the broader situation? Who
(madness, for example) only in certain specific ways and (individually and collectively) is involved (supportive,
not others. ‘A discourse’ would then be whatever constrains opposed, providing knowledge, materials, money,
what else?) in producing these discourses? What and
– but also enables – writing, speaking, and thinking within who do these discourses construct? How? What and
such specific historical limits”.[21 p31] If we look at the whom are they in dialogue with/about? What and
who do these discourses render invisible? How? What
awareness campaign as something that is part of a discourse material things – nonhuman elements – are involved
about mental illness, what then is said about mental illness? in the discourses? What are the implicated/silent
What discourse(s) can be identified, how does it “constrain” actors/actants? What were the important discursively
constructed elements in the situation? What work do
the way mental illness is perceived and, in the process, come these discourses do in the world? What are some of
to shape what it means to be (ab)normal? As Rudge, Holmes, the contested issues in the discourses?
and Perron[22] argue, turning to a critical discourse analysis Based on these questions, we created a disorganized
enables a closer look at the elements that structure and are situational map to identify all the analytically pertinent
structuring debates over truth(s). elements within the situation of inquiry (messy map).
The way in which the campaign attempts to defeat stigma Following this brainstorm exercise, we displayed each
related to mental illness—that is, through the references to element onto an organized situational map using the
internal (biological) disruption—encouraged us to critically categories provided by Clarke.[4 p193] That is, the elements
examine the words displayed in the ads, to map the discourse identified in the disorganized map were regrouped into
practices involved in the production and interpretation of categories to start drawing links between these elements
the messages featured in this campaign, and to situate the and, in the process, engaging in the analysis of the data. As
campaign within a much broader social context. Based such, creating the organized map allowed us to situate the
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EXPOSING THE EXPERT DISCOURSE IN PSYCHIATRY
awareness campaign within a particular political context. We the capillaries of society by attempting to shape individual
noted that the campaign was part of broader governmental conducts in various ways.[26] In the interest of health,
and cause marketing strategy to diminish stigma associated the CAMH campaign seeks to address the growing public
with mental illness but was also a branding exercise for the health threat of mental illness – it seeks to force a review of
CAMH organization. how we think and act regarding mental illness in order to
facilitate access to proper treatment, by establishing proper
As with other public health campaigns, we can locate the
forms of interactions and capitalizing on the conformity and
present campaign within a governmentality framework, since
rationality of each member of that population.[23]
it deals directly with the management of a population.[23]
Governmentality, a term coined by Foucault,[24] can be The campaign can also be situated within the logics of the
understood as society’s general mechanisms of governance in free market, where consumption of psychiatric services
that it is concerned with those practices that try to shape the is based on brand image in order to “sell” mental illness
beliefs and the conducts of a population – practices that are and mental health services. In analysing the Defeat Denial
deeply embedded within a network of power relations which campaign, there is a clear emphasis on communicating a
cannot be reduced to the state and its official institutions. branded health message, one that positions mental health
[25] According to Foucault,[24] governmentality relies on a as an issue that transcends any one advertisement. That is,
specific security apparatus in the government of conducts. “[b]rands position their objects in the lives of consumers in
Contained within this apparatus of security are public health the larger social and physical environment in which we live”.
campaigns since they play an important role in maintaining [27 p722] For example, the biopsychiatric understanding of
social order.[23] That is, governmentality is ensured by mental illness, as well as its reference to scientific progress,
specific forms of knowledge (e.g., scientific), which in turn helps create a social norm with regards to mental illness
permit the establishment of norms, serve as the basis for the as a disorder that finds its origins in malfunctioning brain
development of expert discourses, and are used to penetrate circuitry. This norm thus contributes to creating a social
Table 1: Major Discourses
Epidemiological Referring to the use of statistics as an objective representation of mental illness (prevalence of the
problem).
Scientific/technological Referring to the use of the term “science” and its superlatives (ex. next generation brain science) to
give authority to the campaign, explain and validate the work that is being done and support the
claims made in the posters.
Biopsychiatric Referring to the construction of mental disorders as biological disorders thus framing our under-
standing of mental disorders and positioning the brain as the site of investigation. Ex. References to
brain circuitry as somehow “disrupted”.
Economical Referring to the links made between mental health and its effects on productivity but also highlight-
ing the importance associated to mental health issues (research funding).
Therapeutic/altruistic Referring to language that claims to be supportive, caring, motivating, accessible, understanding,
etc.
Normalizing Referring to elements in the posters that establish or make reference to some form of standard - the
consumption of mental health services (notably hospital services); mental illness has to do with dis-
ruption in the brain; being free from mental illness and the link to productivity (going to work), etc.
Chronicity Referring to the emphasis placed on the brain and the need to acknowledge that mental illness can
last a lifetime.
Promotional Referring to the action of promoting certain behaviour as well as the work of the organization
(branding).
Emotional Referring to the emotional impact of the campaign itself (shock) including effects such as: shame,
guilt in seeing how we dismiss mental health issues, but also the hope that new scientific discoveries
will bring to our understanding of mental illness.
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environment in which understanding mental illness as a contained in the situational map (including other major
brain disorder becomes the gold standard and informs discourses). By making connections on paper (returning
future research and treatment. In this case, branding can to the disorganized map and using a the expert discourse
be seen as a biopolitical strategy in that it is evaluated on as the center of the relational exercise) we reiterated the
the “formation of associations between the individuals inherent assumptions of the campaign whereby dismissive
exposed to branded health messages and adoption of messages are associated to a lack of knowledge about
health behaviours”.[27 p722] Understanding mental illness mental illness on the part of the public resulting in a lack of
as a brain disorder materializes the messages found in the consumption of mental health services by those considered
campaign – mental illness is very real and has a devastating to be suffering from a mental illness (2/3 of people suffer
impact – and should not be dismissed. In this case, CAMH’s in silence). Here, ‘shock’ is considered to be the best way
references to objectivity through the language of science and to increase awareness of the effects of mental illness in
inclusion of individual experiences of people who live with the general population, but also to solidify the psychiatric
mental illness enable them to represent themselves as ethical expertise at play in the campaign and to change individual
and responsible actors in the battle against stigma and the attitudes and behaviours. From this perspective, the difficulty
denial of mental illness. Amidst the scientific discourse of in recognizing mental health issues in fellow human beings
the campaign, however, is the lack of critique that it implies. and the subsequent use of dismissive messages is represented
As with Jenkins,[28] we are conscious of the multiple forces as an unwanted behaviour which takes place when we (the
shaping our understandings of ‘mental illness’ and cannot general public) lack proper understandings of mental illness.
ethically rely on an oversimplified biomedical view, one that In the campaign, the consequences of mental illness are very
has come to gain hegemony in healthcare to tackle what real (possibly chronic and disabling) and affect a relatively
some consider to be societal problems. In other words, the large number of Canadians. The public lack of sensitivity/
mapping exercise used to analyze the campaign enabled us knowledge regarding mental illness, therefore, can be
to draw a close attention to the politics of knowledge at play understood as a prerequisite for the consumption of “shock”
within the text and reinforced the need to look at those other messages and, subsequently, the self-realisation of deviant
ways of understanding mental illness that remained silent in behaviour and uptake of a prescribed social norm such as
the campaign. the recognition of mental illness in fellow human beings and
the consumption of mental health services. In this sense,
The map also demonstrated how the campaign highlighted
the stigma associated with mental health and the associated
the negative ‘impact’ of the illness by playing up its chronic,
dismissive messages are used to construct meaning around
debilitating effects to rationalize the incongruence of
mental illness, but also disseminating a certain normalized
dismissive attitudes towards people with mental illness.
message that (re)repositions the psychiatric institution as
In fact, we noted that the statistical data utilized in the
a place of care, understanding, knowledge and scientific
campaign was a key element in the elaboration of the
innovation. In other words, it is not only the stigma of mental
prevention campaign, in that it highlighted (made visible) the
illness that is addressed in the campaign, but also the stigma
harsh ‘reality’ of mental illness and the need to acknowledge
of psychiatry in general that is targeted.
it; but it also offered a structure to promote CAMH’s (bio)
psychiatric research by framing it within an ethos of hope In this case, mental illness is described within a linear,
and humanized care – a subject that we will revisit later on decontextualized, biopsychiatric model – one that is
in the paper. The most important feature of the organized presented as a rational action to deal with mental health
map was the identification and reorganization of the major issue and that remains silent on the context in which mental
discourses related to the situation of inquiry (see Table 1 for a health issues arise since the individual body is represented
list of major discourses identified in the situation of inquiry). as the site of disease in need of social recognition. It is the
defective brain and, by extension, the individual body that
After examining each discourse within the situation of
is the locus of otherness. If the campaign aspired to help the
inquiry (awareness campaign) and organizing/analysing the
public understand human diversity, recognise suffering and
disorganized map, we chose to focus on the expert discourse
foster change in attitudes, it nonetheless reduced human
as a way to create a space for critique. This decision was
experiences to a common feature: that there exists a certain
the starting point of another analytical exercise (relational
normal brain circuitry and that mental illness results from its
analysis), which was conducted to investigate the relationship
disruption.
between the expert discourse and numerous elements
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Based on our analysis, the awareness campaign is inherently explain, it is also about what there is to explain. That is to
political because it is deployed by an organization with say, it shapes and establishes the very object of explanation,
the clear objective of both penetrating the collective and the set of problems, issues, phenomena that an explanation
personal domains to manage/govern the population and is attempting to account for”.[5 p12] If we take for example
their individual behaviours, thoughts, etc; but also promoting the issue of mental illness, a new molecular style of thought
their own agenda as an organization. Unsurprisingly, then, opens the way for a whole new variety of explanations
the use of these messages to which we should identify with that reside within the molecular structure of the brain. In
are perceived as an effective strategy to create a state of that process, other ways of looking at the phenomenon
discomfort, but also to shape the way we come to understand of mental illness are marginalized. As with Jenkins,[28]
what mental illness is. In the following segment, we expand we understand this marginalization to be a symptom of
on the use of the expert discourse in the awareness campaign contemporary politics of knowledge where scientific (read
by making connections with Rose’s concept of the “biological objective and experimental) knowledge has achieved a form
citizen”[5] and Foucault’s concepts of subjectification and of elite status and is considered to be an ideal necessary for
power-knowledge dynamics. societal progress. In this case, the ’science’ promoted in the
campaign is one that is closely linked with a biomedical
Expert discourse view of mental illness. In effect, the somatic expertise that
According to Rose,[5] there is a recent shift in the way human is presented in the campaign is central to the truth discourse
life is understood. If for the greater part of the 19th century about mental illness. In the campaign, we can appreciate
scientists and lay people have focused on “the visible, tangible how the centrality of the brain (and its malfunction) becomes
body”,[5 p11] we, as a collective, seem to be entering an era fertile ground for novel forms of regulatory strategies. Here,
that is marked by an intensification of what can be seen. We it is not so much the responsibilization of individuals in
now speak of another type of visibility and understanding, managing their brains to stay healthy that is at stake,[30] but
one that takes place at the molecular level. As such, we are rather our responsibility as good citizen towards others by
witnessing a shift in the way health and therapeutic successes conceptualizing mental illness as a disorder of the brain and
are conceived, in that they are implicitly framed in molecular increasing our capacity to recognize it.
parameters.[30] This shift also implies a certain loss of agency As indicated earlier in the paper, the structure of the campaign
in those who feel unhealthy in that subjective experiences of facilitated the promotion of CAMH’s (bio)psychiatric research
health are now reinterpreted in light of so-called objective/ by framing fears and anxieties associated with mental illness
observable measures. This reinterpretation is, in part, the within an ethos of hope and humanized care. Known as
purview of those who claim to have some form of somatic ethopolitics, this technique seeks to “shape the conduct of
expertise which becomes the vehicle of truth about one’s human beings by acting upon their sentiments, beliefs and
health-illness experience. As Jacob and colleagues argue,[29] values”.[5] Here, Rose speaks of how people come to see
the expert medical discourse exerts a considerable control themselves as biological selves, and will evaluate and act
over the perceptions of one’s experience with illness, upon themselves in terms of this belief in what we understand
therapy and more importantly, one’s body and emotions. The to be a process of subjectification. The campaign is, in some
campaign, for example, by focusing on the brain, acts as a respect, geared in this this manner, where people are shocked
medium through which the expert discourse fosters a (bio) by the ‘effects’ of mental illness as well as its dismissive
psychiatric translation of individual illness experiences, thus messages, and should engage in a reflection which would
silencing other forms of understandings (knowledge). eventually lead to an implicit reconceptualization of mental
Here, Rose[5] speaks of a new style of thought and argues illness as a brain disorder. That is, the biomedical view offers
that with it comes new ways in which human beings will a logical, sanitized explanation of mental illness, but it also
come to experience themselves as biological selves, but narrows the possibilities to deal with this issue by framing
also shapes new forms of government and expertise. As with the way we permit ourselves to see, act, and feel towards
Rose,[5] we understand this molecular style of thought as “a mental illness. In its attempts to normalise mental illness
particular way of thinking, seeing, and practicing. It involves and eradicate stigma, the campaign reinforces biomedical
formulating statements that are only possible and intelligible hegemony which grants certain experts exclusive rights to
within that way of thinking. […] A style of thought is not speak and act, relegating other ways of conceptualizing the
just about a certain form of explanation, about what it is to issue as invisible influences.
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Moving beyond the expert discourse: Expanding [33 p24] We wonder, in this case, if the change in attitudes
on the (bio)psychiatric roots of stigma has more to do with the uptake of mental illness as a brain-
based illness, rather than as a real change in publicly-held
In this section, we consider the claims of anti-stigma
attitudes towards those living with mental illness. We can
proposed by the campaign as they (the claims of the
understand here how the campaign describes success,
campaign) focus on the brain and attempt to normalise the
in that a high level of mental health literacy, in this case,
experience of mental illness. Literature on stigma unearths
is a measure of the capacity to shape the way people see
the potential (negative) effects that may follow such a
mental illness – regardless of its actual “anti-stigma” effects
campaign. As with Phelan,[2] it is possible to appreciate the
in terms of behaviours towards people with mental illness.
hope that is associated with the biological understandings
The challenge in this situation, and in light of the scientific
of mental illness but nonetheless remain skeptical on its de-
reference that is promoted in the campaign, is to question
stigmatizing properties. In the campaign, the bio-psychiatric
whether there is another way to understand mental illness—
discourse is played-up and portrayed as a possible solution to
one that does not hold the bio-psychiatric discourse as the
reduce stigma—i.e., that current understandings of the brain
only ‘truth’ about mental illness. In effect, studies consistently
through science will lead to such an outcome. Despite the
show that emphasizing the psychosocial origins of mental
undoubtedly good intentions of the campaign, it is puzzling
illness are more likely to affect attitudes positively whereas
to appreciate why an anti-stigma campaign would centre
emphasizing the biological understandings of mental illness
on the biology of mental disorders given that “evidence
do just the opposite.[31]
actually shows that anti-stigma campaigns emphasizing the
biological nature of mental illness have not been effective, The campaign must, therefore, be considered as an attempt
and have often made the problem worse”.[31 p190] As Read, to improve our ‘mental health literacy’ by increasing the
Halsam and Magliano [32 p158] argue: ‘evidence-based’ knowledge that positioned mental illness as
[t]he core assumption of most anti-stigma programmes a brain (biologically) based illness, and, arguably, strengthen
is that the public should be taught to recognize the the traditional link between medicine and pharmacological
problems in question as illnesses or disease, and to treatment. As with Read et al.,[31] we concur that campaigns
believe that they are caused by biological factors
like chemical imbalance, brain disease and genetic promoting such a message are far from being evidence-
heredity. The thinking behind this well intentioned based, especially when linking biological origins of mental
‘mental illness is an illness like any other’ approach is
that if we can’t control our behavior, we can’t be held illness to reduction in stigma. In this case, using a biological
responsible and, therefore, can’t be blamed. It is the explanation (disrupted brain circuitry) as the root cause of
‘mad not bad’ argument, with the mad part portrayed
as biologically based illnesses. mental illness only accentuates the burden of disease by
situating the problem within the person, rather than to engage
The campaign is not unlike previous public health efforts
in the difficult task of addressing the contextual elements that
to increase our mental health literacy; that is, increase the
may be at the source of the problem. As Read and colleagues
“knowledge and beliefs about mental disorder which aid their
argue,[31] turning up the volume on biopsychiatry
recognition, management and prevention”.[31 p159] As with
reinforces an essentialist view of mental illness--one often
the current campaign, we are ‘literate’ if we ‘understand’ that
associated with an increased social distance, a poor view
mental illness is very real, potentially chronic, and may be
on recovery, and a perspective that (re)produces stigmatic
devastating; that we can ‘recognize’ behaviours as examples
behaviour. This is not to say that biopsychiatric research is
of a particular psychiatric illness and as a result, modify our
not important. Much to the contrary, biospychiatric research
own attitudes and behaviours towards those who experience
is important as it remains one way to produce knowledge.
them because we ‘know’ that, for the most part, they are
Nevertheless, we need to be cautious not to mistake research
caused by a disruption in brain circuitry and arguably, that
endeavours for “truth” about mental illness – especially
we ‘believe’ in treatment using psychiatric drugs.[31]
when it is established that addressing social issues (e.g.,
Thus, mental health literacy is, in large part, framed within housing) have as much of an impact on mental health, if
a particular discourse about mental illness – one based on a not greater, than other biological interventions. According
biological/essentialist understanding of its causes. According to Jenkins, the “hegemony of biomedical knowledge
to CAMH’s 2012-2013 annual report, 74% “of Ontarians within healthcare research and practice comes at a cost” in
surveyed who saw CAMH’s Defeat Denial awareness which “other mechanisms underlying illness and disease,
campaign reported changed attitudes toward mental health”. such as social, economic or psychological factors, are
2015: Vol.7, Numéro 1/Vol.7, Issue 1 13J D JACOB
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not adequately explored or attended to”.[28 p2] As such, campaign as both an awareness campaign and branding
the biologicalization of mental illness “diverts attention exercise led to an array of embedded assumptions about
and resources away from social, political and spiritual the origins of mental illness and its association with stigma.
understandings of distress and is testimony to the power of Not only does this paper re-affirm biomedical hegemony in
[bio]psychiatry to create subjectivities”.[34, p.84] To remain the way messages about mental illness are conveyed to the
uncritical about such campaigns is to understand that it not public, it also highlights the difficult association between
only acts upon us in trying to change our behaviours, but also the organization’s agenda (playing up the biological roots of
through us. What we think we know about mental illness mental illness) and the issue of stigma which is proven to
shapes how we understand ourselves as human beings—to be accentuated by such biological claims. We must remain
cast a narrow view is to dangerously constrain possibilities critical of such awareness campaigns as they not only
for understanding, action and subjectivity. constrain how we can think about mental illness but also
run the risk of increasing stigma despite our best intentions
Final remarks to reduce it.
The language of brain circuits, in reference to brain structure
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annual estimates, by age group and sex, Canada, provinces,
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2015: Vol.7, Numéro 1/Vol.7, Issue 1 14You can also read
